Treatment of AO/OTA 43-C3 Pilon Fracture: Be Aware of Posterior Column Malreduction

Abstract

Treatment of pilon fractures remains challenging due to the difficulty of fracture reduction and associated soft tissue complications. The aim of this study was to evaluate the pitfalls and strategies of posterior column reduction in the treatment of complex tibial pilon fractures (AO/OTA 43-C3). Thirteen AO/OTA classification 43-C3 type pilon fractures treated between January 2013 and January 2016 were retrospectively analyzed. Nine cases were treated by external fixation within 26 hours (range, 6–56 hours) after injury. The definitive open reduction and internal fixation (ORIF) was performed after the wound was healed without infection and soft tissue swelling had subsided. During the delayed/second-stage operation, the articular surface of the distal tibial plafond was reduced through the posterolateral and anterior approaches. X-ray and CT scans were performed pre- or postoperatively. The reduction quality was evaluated using Burwell–Charnley’s radiographic criteria. The follow-up was performed routinely and all complications were recorded. Ankle function was evaluated using the American Orthopedic Foot and Ankle Society (AOFAS) ankle-hindfoot score. During the delayed/second-stage operation, primary reduction of the posterior column was performed entirely through posterolateral approaches. However, poor posterior column reduction was revealed by fluoroscopy in four cases, three of which were readjusted through the posterolateral and anterior approaches, and the fourth was adjusted directly through the anterior approach. Postoperative CT scan revealed that the step-off of the articular surface was less than 2 mm in 12 cases, and in only one case the step-off was greater than 2 mm but less than 5 mm. The satisfactory rate was 92.3% according to Burwell–Charnley’s reduction criteria. Eleven patients were followed up regularly; superficial infections occurred in two cases but healed after wound care treatment in 3 and 5 weeks, respectively. All eleven fractures were healed within an average of 3.6 months (range, 2.6–5 months). The average range of ankle motion was 19° of dorsiflexion and 28° of plantar-flexion. The mean AOFAS ankle-hindfoot score was 82 (range, 61–92). In our opinion, we suggest that the reduction of the articular surface should be performed through combined posterolateral and anterior approaches in a delayed operation, with flexible fixation of the posterior column. If the posterior column is poorly reduced, the articular surface can easily be manipulated through anterior approaches. According to this strategy, satisfactory outcomes of AO/OTA C3 pilon fractures would be anticipated.

Fusion versus fixation in complex comminuted C3-type tibial pilon fractures: a systematic review

“…In these articles, the outcomes were reported as the total number of the complication of interest for 1 treatment group compared with another treatment group, but without distinction as to whether the complication occurred in AO 43-C1 or AO 43-C3 injury or the status of the skin at the time of injury. The remaining 13, with 8 articles reporting a staged approach [3,15,[24][25][26][27][28][29] and 5 articles pertaining to primary arthrodesis [8,[20][21][22][23] were evaluated and analyzed. The 13 studies examined in this review included 377 total fractures, 228 of which involved AO 43-C3 pilon fractures.…”

“…The authors classified treatment groups in the included studies according to the use of fusion procedures. Five studies [8,[20][21][22][23] used fusion procedures, 8 studies used other types of treatment [3,15,[24][25][26][27][28][29] (Table 1). Weighted analysis, using sample sizes reported in each article, was used to compare these 2 patient groups on key indices.…”

Comparison of Computed Tomography, Traction, and Inverted Grayscale Radiographs for Understanding Pilon Fracture Morphology

“…In the presence of posterolateral fragment, reduction and temporary fixation of the posterolateral fragment is recommended as the first step of the articular reduction. 13 Guan et al 3 reported satisfactory results with the use of the combined posterolateral and anterior approach which posterior cortical reduction takes the first place. Ketz and Sanders 4 conclude that proper reduction of the posterolateral fragment is a reference point for the remainder of the surgery.…”

A Current Concepts Update in Pilon Fracture Management

“…Pilon fractures are classified according to the Ruedi and Allgower system and the OTA/AO fracture classification system. Ruedi and Allgower split the tibial ceiling fracture into three types based on their displacement and comminution level from the articular surface (Figure 6) [1], [21], [22].…”